The future is now: comment on a recent editorial suggesting the need for a new technology in the treatment of des restenosis.

In a recent editorial, John S. Douglas Jr. elegantly describes the issue of drug-eluting stent (DES) restenosis (1). This editorial refers to the RIBS (Restenosis Intra-Stent: Balloon Angioplasty Versus Drug-Eluting Stent) III trial, a study whose aim was to compare different strategies for the treatment of DES restenosis, and whose findings revealed that choosing a different DES provides better angiographic outcome than alternative interventional treatments (2). The comments of Douglas are relevant, and we especially agree that a longer follow-up would probably catch more DES restenosis and that post-procedural minimal lumen is generally smaller with balloon angioplasty than with stent implantation, due to acute elastic recoil or tissue prolapse. However, we believe that the editorial title claiming the need for a new technology for the treatment of DES restenosis is misleading and deserves some comments. Indeed, it is already here. Drug-eluting balloons (DEB) represent a breakthrough technology that has found its land of conquest for the treatment of in-stent restenosis. The advantages related to DEB use are extremely relevant, including local drug delivery with burst paclitaxel release, need for short dual antiplatelet therapy, diffuse and homogeneous rather than strut-related drug distribution, and lack of a further metallic layer. With regard to DES restenosis, the effectiveness of DEB was first assessed in a small trial recently published in JACC: Cardiovascular Interventions that showed significantly lower late lumen oss in patients with sirolimus-eluting stent restenosis who were reated by DEB angioplasty rather than conventional balloon ngioplasty (0.18 0.45 mm vs. 0.72 0.55 mm, p 0.001) (3). ore robust evidence favoring DEB use in DES restenosis was rovided by the PEPCAD (Paclitaxel-Eluting PTCA Balloon atheter in Coronary Artery Disease) DES trial, which demontrated the superiority of a DEB strategy compared with plain alloon angioplasty in the treatment of patients with both aclitaxel-eluting and sirolimus-eluting stent restenosis, providing less-than-one-half late lumen loss value (0.43 0.61 mm vs. .03 0.77 mm, p 0.001) and almost 4 less binary restenosis 17% vs. 61%, p 0.001). Moreover, the pattern of restenosis in he plain balloon group was focal in 72% of patients and less omplex than in the DEB group (4). Restenosis after DES implantation has specific morphological atterns and tissue composition, making it particularly challenging o treat. Although a direct comparison is not available, DEB ngioplasty for treatment of DES restenosis seems to be associated ith lower or at least equivalent need for reintervention when elated to DES use. The recurrent use of a DES, however, involves he addition of a further metallic layer and poorly known drug ehavior. So, given DEB sound pathophysiological premises and good reliminary clinical results, we believe that the time of waiting for new technology is over; we only have to give a glimpse at it on ur shelf!